<div class="ui raised very padded text segment">
    <div class="ui form">
        <div class="inline fields">
            <label for="orderSource">城市</label>
            <div class="ui selection dropdown">
                <input type="hidden" name="cityId" value="">
                <i class="dropdown icon"></i>
                <div class="default text">请选择</div>
                <div class="menu">
                    <% data.forEach(function(row){ %>
                        <div class="item" data-value="<%=row.cityId%>"><%=row.cityName%></div>
                    <% }); %>
                </div>
            </div>
        </div>
        <div class="inline fields">
            <label for="region">商家联系人</label>
            <div class="field">
                <input class="five-input" type="text" name="contactUser" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">商家手机号</label>
            <div class="field">
                <input class="five-input" type="text" name="contactPhone" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">商家名称</label>
            <div class="field">
                <input class="five-input" type="text" name="name" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">商家登录帐号</label>
            <div class="field">
                <input class="five-input" type="text" name="account" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">登录初始密码</label>
            <div class="field">
                <input class="five-input" type="text" name="password" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">商家简介</label>
            <div class="field">
                <input class="five-input" type="text" name="introduction" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">车队数量</label>
            <div class="field">
                <input class="five-input" type="text" name="teamNum" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">司机1联系电话</label>
            <div class="field">
                <input class="five-input" type="text" name="driver1Phone" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <label for="region">司机2联系电话</label>
            <div class="field">
                <input class="five-input" type="text" name="driver2Phone" placeholder="">
            </div>
        </div>
        <div class="inline fields">
            <button class="ui button" id="supplierAddBtn" type="submit">提交</button>
        </div>
    </div>
</div>
